Medical decision making: What is it, why is it important and what steps are involved?

Insight Article - August 29, 2019

Coding & Documentation

Medical decision making (MDM) represents the provider’s cognitive work when seeing a patient and is the most important of the three components required to level an E/M service. 

Some payers look mainly at MDM when determining medical necessity, which is the overarching criterion for payment. This is because the risk portion of MDM (risk of complications and/or morbidity or mortality) is closely tied to medical necessity. Some payers even require MDM as one of two factors when leveling services for subsequent or established patients. Furthermore, the Centers for Medicare & Medicaid Services (CMS) is moving toward requiring only MDM as the sole leveling factor for outpatient visits. Such a move could set the standard with other payers. Given its importance, MDM deserves a thorough review.

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About the Author

Beverly Gibson
Beverly Gibson MBA, M.Ed., CMPE, CPC, CPC-I, CPMA, CEMA, CIFHA

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